你和他說法律，他和你講道德；你和他講道德，他會和你說政治；你和他說政治，他就跟你講民意；你跟他講民意，他跟你耍流氓；你跟他耍流氓，他就跟你講法律！

你和他說法律，他和你講道德；你和他講道德，他會和你說政治；你和他說政治，他就跟你講民意；你跟他講民意，他跟你耍流氓；你跟他耍流氓，他就跟你講法律！

Yes, you do not read it wrong.  The title of this Editorial is in Chinese characters.  But I am going to write in English.  In case you cannot read Chinese characters, do not expect me to explain them in English.  To talk with you without engaging in any meaningful discussion, or even not talking in a common language, is my purpose.  It is also the gist of the meaning of the quote of the title.  And, sadly, it is now the norm of meetings and dialogs, and the root of conflicts.

When I studied law, I learnt this adage: “When the facts are not on your side, argue about the law.  When the law is not on your side, argue about the facts.  If both are not with you, talk about the weather.”  There were different versions; they differed by how to handle when both the law and the facts were not on your side.  Those included yelling like hell, or calling your opponents names, or pounding the table.

There is much wisdom in this adage.  It reminds students and lawyers that there are two major components in defending a case: the facts and the law.  You do not need to attack on both.  You just need to poke a hole on either.  It is about defense tactics.  Pound on favorable points and avoid harms.  Talking irrelevance might also distract jurors.

However, I am smart enough to realize the true beauty of the adage.  After all, I am not a lawyer and court room strategies are not really vital to me.  The most important point is to know that there exists such a tactic and to recognize it when someone else is practicing it.  See?  If you are the prosecution, you need to keep on tract and counteract with what is on your side.  But it is the judge who matters most.  He needs to keep his mind clear and not to be distracted by dramatic presentations.  The whole picture should always be in his mind.

It is perfectly acceptable and in fact good practice for a defense lawyer to pound on whatever he finds fit and of benefit to the defendant.  There is always the judge or the jury to decide.  However, it is not so desirable when you encounter such tactics in meetings.  The purpose of holding a meeting is to check on progress and more importantly, to make decisions.  Therefore it is essential to have “meaningful” discussions on related issues.  It is irritating and disgusting to encounter people holding on such tactics.  Those of the lesser evil would try to lure you for a blanket mandate to work on something.  The usual strategy is to talk endlessly on the objective of the project, such as how important it is to treat diabetes, or how primary care can be the solution for our health care system.  Details on how to achieve such objective is never proposed or discussed.  Direct inquiry on any substance on implementation will be met with circumferential referral to the objective again, and again, and again.  These people are referred to as of lesser evil because they are not in power.  They can continue their oral diarrhea as long as they wish.  You just have to keep alert, and to keep healthy so as not to be out-lived by them.  Of course in the mean time, a significant portion of your precious life is ruined by them.

Of greater evil are those in power using such non-engaging strategy.  When they are caught acting ultra vires, they talk about the weather.  I have met such greater evil more and more commonly in recent years.  Some of them reiterate how holly the objectives are.  Some of them play judges and declare that they are legitimate to do so.  Most of them fall into a pattern as described by the title of this editorial.  Literally it starts with the law.  When you challenge them with the law, they preach ethics.  When you reason in ethics, they go into politics.  When you talk about politics, they refer you to public opinions.  When there are public opinions, they play dirty.  When you go extreme, they have the law against you.  I wonder if there are training courses on such tactics.

You have no way out.  You cannot ignore them, as there are wrongs to rectify.  There exist formal and official ways for redress.  But most of them are expensive and time consuming.  Being in power means that they are resourceful.  They can easily drag on and worn you out, using your money in most of the time.  They have the manpower, from secretariat to civil servants, to write and to fight.

In the past, we did see people in power resigned when there were uproars.  They felt shameful.  Nowadays, most of those in power (any power) have attended the non-engaging-tactic-training-course.  When challenged with ethics, they have no room to feel shameful.  They need to non-engage you with politics.  Thus, they are either correct politically, or they will tell you that it is more difficult to stay than to resign.

I have identified the root cause for dysfunction meetings, corrupted boards and councils, and the increasing violence in the society.  I have no solution to it.  Readers can either alert yourselves with the above-mentioned tactics, or you can go and find out where to enroll in a training course on it. 

(Source: HKMA News July 2015)

Out Of Focus

It was too hot.  My mind could not function.  Things, events and concepts became out of focus.  It was just like wearing the wrong pair of glasses from your super-myopic-and-ugly classmate in high school.  No matter how hard you strained your eye muscles, or strained my neurons, I could only figure out blurred images.  I could barely distinguish a deer from a horse, provided that they were near enough, and not in any disguise.   

I did not know how long this condition would last.  I told myself, that summer would go away, followed by winter.  This was the weather of Hong Kong, the old Hong Kong we knew.  The old Hong Kong we studied in high school geography.  After a few months, it would not be equally hot.  My mind would clear up then.  I told myself, repeatedly.

At the back of my out-of-focus mind was my presbyopia.  It did not get better after several summers.  It only got worse month by month.  Suppressing the memories of the good old days when I painted at ease the moustache of a 1:72 soldier, I got a pair of reading glasses.  I wore shirts more often so that I could keep and retrieve the glasses at the breast pocket more conveniently.  I gave up paper-backs and got a kindle.  It was a reading device without back-lit.  It strained the eyes less.  Most importantly, the fonts could be adjusted to an unbelievably large size.  I had to live with it.  I have to live with the presbyopia.

While there were well documentation and statistics for reflective errors, I did not think there was any formal measurement and study on blurring of mind.  I had estimated that in my 25 years’ practice, I should have seen around 100,000 patients and relatives in more than 300,000 consultations.  It was quite alarming that I had an impression that a significant proportion of them got blurred minds.  Of course there was no objective measurement.  And it was not fair to assess them when they were physically sick and mentally preoccupied by their illnesses.  So I just quote some examples and readers could try to figure out what I meant.  A university student applied some cream of unknown ingredient and unknown origin to his finger with cellulitis and was quite curious why the condition got worse.  A financial consultant tried 4 years, in vain, to control his sky high cholesterol level with various methods he learnt from discussion forum.  A teacher refused to give antibiotics to her daughter with scarlet fever because she knew that antibiotics were not good.  A businessman refused to take antihypertensive medicine because he was sure that once started, treatment could not be stopped.  A shop manager, agreed with her insurance agent, thought that it was the duty of doctors to find out some means for her to claim insurance for accidental injury that she did not suffer.  An accountant educated me that it was patients’ rights to have regular sick leave 2 days per month.  A barrister was offended because I charged her consultation fee for writing a referral letter.

I planned to go on and filled the whole page with examples.  It was so reassuring that I was not the lone ranger here.  Out of focus, I saw no difference in the survey results between those supported and those voted against the Government Proposals for Selecting the Chief Executive by Universal Suffrage.  Afterall, when this Editorial reaches our members, the outcome would have been determined.  Frankly, how many people know exactly the details of the Proposals?  How many people can elucidate the pros and cons hidden between the lines?  I agreed totally with the tycoons that most people in Hong Kong cared more about earning money than who was going to be the next Chief Executive.

Nonetheless, how come nearly 7,000 members responded to our survey?  How come tens of thousands of citizens made history by staying on the street for 80 days?  How come students stood firm against police batons?  How come people took all the trouble, risking being charged criminally, to nail the state-of-art banner on the Lion Rock Hill?  I did not know the answer.  I do not know the answer.  And I will not know the answer.  With clouded mind, I tried to make a guess.  It was not because of the Basic Law.  It was not about the 831 decision.  It was not about the Proposals.  It was all about the way it was handled.  In the battle between David and Goliath the giant, if Goliath repeatedly hit below David’s belt, what would happen?

The weather is still hot.  My mind is still out of focus.  Politics are difficult to understand and taboos to write on.  It must be the weather that caused my mind to drift to the survey and the Chief Executive Election.  It must be the weather that caused me to write on this topic.  Or, is it now the only moment that my mind is clear enough to see the real nature of my all-along-clouded mind?

(Source: HKMA News June 2015)

Pocket First?

 

The cover story of the HKMA News this month is about the HKSAR Government’s Proposals for Selecting the Chief Executive by Universal Suffrage.  To be exact, we are actually highlighting the questionnaires sent to members asking whether they choose to support the Proposals or not.  Some people treat this survey very seriously.  Within this Council, there have been lengthy discussions on each and every aspect of the survey, from wordings of the questions, to how many questions, to methods of distribution and return, to whom to send, and to methods of analysis.  There are members writing to the Forum expressing their opinions and urging others to do so via our survey.  I even received a forwarded email from Professor David Todd (of which I doubted the authenticity very much), saying that “… I would like to appeal to you to speak your voice when the new survey comes out.  We should no longer stay in the sidelines as the silent majority.”

As if it really matters.  This is what I think when reviewing what happened after our previous responses to the consultation papers and the events in October last year.

For this survey, there is only one question is asked.  It is very straightforward.  You just state whether you support the Government Proposals or not.  There is no “if” or “provided that”.  You can take it, or beat it.  As a doctor, I must admit that I do not know how to respond.  We are advised by the Code of Practice and well-circulated court cases that doctors need to provide options for treatments to patients.  The pros and cons of each option need to be explained fully.  Even rare side-effects need to be addressed if they are considered significant to the patient by common sense.  However, for the choice between accepting the Proposals or not, several crucial and fundamental questions remain unanswered.  No one knows with any certainty what would happen if the Proposals are rejected.  Neither can anyone tell when or how the proposed methods, if adopted, can be modified or “up-graded”.  The Government is hard-selling its miracle drug.  Side effects are rarely mentioned or analysed.

I have to transcend my mode as a doctor so as to make a choice.  Can lawyers choose better?  They are good at selling lopsided theories to help their clients.  However, I guess they are none the wiser to choose between such theories.  I need a judge instead.  Afterall, the dispute arises from the interpretation of statute, namely the Basic Law of Hong Kong, particularly Article 45.  The duty to declare whether the Proposals satisfy the statute should fall on a judge.  However, by some unknown reasons, for better or for worse, I am now asked to decide, as if it really matters.

Laymen do decide cases in some circumstances.  There are jurors in criminal cases and defamation cases with leave from the judge.  Before the jury retires to deliberate, the judge will give directions to help their decision making.  Apart from guidance and explanation on legal principles, the directions are built on logics.  To facilitate my thinking process, I self-talk some directions to myself as follows.

I call what we have now for Chief Executive selection A, the Government Proposals B, and what we should have as promised C.  To over-simplify matter, I am not treating any of them as better, since different people can have different preference and interpretation.  What we have to decide now is simply whether to support B.  It is assumed that by rejecting B, we are left with A.

Apparently, B is not the same as C.  This is reflected in the slogan of the Government asking people to “pocket first”.  But, if you think that B is no difference from C, then you should support B.

If C does not bother you, you can forget about C.  Your decision then solely depends on whether you prefer A or B.

If you want to have C in the foreseeable future, then you need to consider whether B or A would have a higher chance of leading to C.  If you think that B is an inevitable step between A and C, then you should support B.  If you think that B would side-track the route from A to C, which means that it decreases the chance of reaching C, then you should reject B.  The reverse also applies.  If you do not want to have C, you can choose accordingly.

If you long for C, but is smart enough or as pessimistic as to know that there will never be C, you should allow yourself to moan for a while.  Then you should think about whether you prefer to live with A or B for the rest of your life.  You have to consider whether B, sold as a palliative treatment, makes you feel better.  You have to decide according to what have been presented to you.  You have to choose which witness to believe.  This is a civil case.  The standard of proof is on a balance of probability.

This time, you cannot take as long as you need.  There is a deadline.  There will not be any hung jury or mistrial.  The outcome will either be A or B.

After contemplating the above directions from the imaginary judge, I realize that it is an ultra difficult decision for me to make.  But I am not worrying, although the clock is ticking.  I am just moaning.

And, please take it seriously in answering the survey, as if it really matters.

 

(Source: HKMA News May 2015) 

Drifting and the College of Primary Care

It is depressing to think about primary care in Hong Kong.  It seems common consensus that primary care is all along not well taken care of by the government.  Resources allocated to primary care are out of proportionally low as compared to secondary and tertiary healthcare.  However, the outcome is not that bad.  Hong Kong people might be unhappy, but they are not in poor health.  Statistics confirm this fact.  There exists a delicate balance among the behavior of citizens, the hard working primary healthcare workers and the government input.

It is not depressing to be a general practitioner, provided that you don’t think too much.  Do ignore the people who called you names out of nothing when the Healthcare Voucher Scheme was first launched.  Do not think about the stressed-to-be-overpaid sum of $50 for vaccinating screaming kids, for explaining pros and cons, for keeping records, and for looking after them for any adverse effects.  Do not watch TV least you see the HMOs promising everything to their potential clients while giving you $105 for each consultation, plus medications, plus writing medical reports, and plus once in a while harassment from them.  Do not try to explain when your learning-to-be-kind relatives or some newly met friends-of-friends ask you “how come” you became a general practitioner rather than a dermatologist.  After twenty plus years of practice, I find it OK to be a general practitioner.  I can earn a living.  I can study or do some reading in spare time within the overtly long working hours.  I, sometimes, even, have a sense of job satisfaction by being able to help my patients. 

It was over joyous to learn that our President had come up with an idea to form a College of Primary Care early this year.  I guessed it would not be an easy job.  But our President must have talked to some big guns, pulled some strings and twisted some arms.  Some colleagues feared that such College might do more harm than good by imposing control rather than support.  Frankly, this fear was also at the back of my mind.  However, when a risk was identified, we could at least try to take care of it.  Eventually, an “Ad Hoc Committee on a College of Primary Care” was formed to work out how and when to set up a College of Primary Care.  Funny name, but some support to general practice might be better than none.

It was sad to read what the President of the Hong Kong College of Family Physicians wrote in “Message of the President” of the Family Physicians Links (March 2015 Edition). “While we welcome endeavours to promote Primary Care, we cannot support the idea of establishing a new College of Primary Care.”  All supposed-to-be-big-guns stayed at home, rubbing their twisted arms.

I was at the verge of depression.  I remembered my psychiatrist friends told me that learning something new might help to overcome depression.  It was depressing, however, that I forgot to ask them whether trying to promote primary care, or forming a college of primary care could help.  So, I decided to put down this college stuff for a while, and went to learn drifting.  From the almighty Wiki, “drifting is a driving technique where the driver intentionally oversteers, causing loss of traction in the rear wheels or all tires, while maintaining control from entry to exit of a corner.” 

I spent 24 hours, flying via London to Arlanda of Stockholm, then changed for a propeller driven plane to Arvidsjaur at the northern part of Sweden.  There was a race course temporarily built on a large frozen lake with 100cm thick ice.  When driving on ice, drifting was not something you learnt to do.  It would happen anyway with even 30km/hr on turning a corner.  Drifting was something to control, and to make use of so as to have fun, or to tackle a corner skillfully.  The instructor taught me to brake hard before entering a corner.  Then entered slow.  “Wait, wait, wait.”  He said.  “When you can see the end of the corner, then gas.”  When I got used to drifting, there were racings on different courses.  There were “hot laps” where the instructors demonstrated what racings were supposed to be.  They practically drifted all the way and the cars were moving side-way all along.  I began to doubt whether cars were built to travel forward in the “usual” sense. 

Practicing and racing from 9 to 4 everyday in -12 degree celsius was fun to many.  However, I was not the competitive made nor the strike-for-perfection type.  My mind now and then began to drift.  I forgot to mention one important point.  For such dramatic drifting, you have to first turn off the Electronic Stabilizing Program (ESP) of the car.  People do not slide or drift easily as in icy road because of the activation of this great system.  I tried driving a round with the ESP on.  Life was much easier.

Drifting is fascinating.  In expert hands, it is the fastest way to cut a slippery corner.  However, in daily lives, we need ESP instead of drifting.  Do we need a novel College before our primary care can function or flourish?  Don’t read me as against the formation of the College of Primary Care.  I am more concerned about the function of the body, whatever it is named.  As mentioned, our system is now delicately balanced.  What we need is not a disturbance of the balance.  We have to consolidate what we have.  Give our primary care workers a hand to stand against unequal terms and adverse conditions.  United in this sense, whatever the body is named, we go for it. 
 

(Source: HKMA News April 2015)

The CM Staging for Carcinoma of City

Just finished reading the new book from Jeffrey Archer.  It was called “Mightier than the Sword”.  It was the fifth book of the “Clifton Chronicles”, and the sixth is to come in 2016.  The first book of the series, “Only Time Will Tell”, was released in 2011.  It was the story of how a shipyard boy, Harry Clifton, born in 1920 England, became the owner of a shipping line.  In “Mightier than a Sword”, Harry was in his fifties.  He became a writer of detective stories.  In this book, Jeffrey Archer told, though very briefly, how a writer’s pen could be mightier than a sword.

After 4 years and 5 books, the story began to lose heat.  It was still typical Jeffrey Archer, but the writer tended to have his attention lapsed.  He was more interested in lingering on than developing the story.  Plots were often oversimplified, sometimes to the point of absurdity.  Harry was able to beat the IRA (Irish Republican Army) and the KGB of the former Soviet Union single-handed.  His escape from danger was purely due to luck.  A hand-shake was as good as a contract.  Public officers would promptly step down when public opinions were against them.  Even the most shameless bad guy killed himself in this book when his crime was exposed.

Wait!  How come I equated valuing a hand-shake promise, or stepping down of public officers with fighting IRA and KGB single-handed as absurdity?  Weren’t these common believes?  Weren’t these once core values?  Had I been changed without noticing it myself?  Are prevaricating and obfuscating the norm now?  Then I read 2 articles in the Next Magazine issue 1304.  Stephen Vines wrote about an enormous scandal in Britain in which advertisers influenced the editorial content of the Daily Telegraph.  What he actually wanted to say was clearly spelled out in the title of the article: No scandal here… unfortunately.  The following page was an article in Chinese by LAM Pun Lee.  He noticed the recent attacks on the University of Hong Kong by different people in different fronts.  He concluded that it was the result of high-rank HKU management bowing to the rich and the powerful in recent years.  The title of the article said HKU invited others to follow suit by insulting herself.

I am not going to exclaim, in high pitch, that “This city is dying!”  But I know that this city is changing.  Or, at least, I am changing.  Motivational interviewing says that changes take stages.  When you try to move someone, you need to move him through such stages.  Buddhism teaches that one should be mindful of his state of mind (leaving alone those masters who can master emptiness).  I thus sat down and contemplated various scenarios in which common core values should have applied.  There were plenty of such.  All I needed to do was just to go through recent newspaper clips.  Though, common core values were no longer common.  I worked out the following 6 stages.

1. Realize that there is a problem and voice out
2. Realize that there is a problem and do nothing
3. Realize that there is a problem and try to take advantage of it
4. Ambivalent about whether there is a problem, as such things are common
5. There is no problem, this is the norm
6. There is no problem, and such practice should be encouraged and promoted

I used my experience as a real life example to illustrate.  In a meeting, a member made an interesting complaint, stating that the inspectors of the Food and Environmental Hygiene Department should be selective in their prosecution.  They should be sympathetic to poor citizens who worked hard to earn their livings in this hostile economic situation.  Obviously this member was at Stage 6.  I was at Stage 2.  I could identify problems with selective prosecution.  The inspectors would soon be threatened with violence or got corrupted.  However, the member looked serious and fierce enough for me to keep my mouth shut.  I was amazed to find that members were roughly evenly distributed among the 6 stages, with the legal advisor assuming Stage 1.  I guessed she was paid to do so.

I believed no one would be interested in the state of my mind, nor whether it had changed to the better or the worse.  However, it might be worthwhile to understand more about a committee, a tribunal or an organization.  How about a city?  My mind reverted back to that of a doctor.  A doctor tended to associate staging with cancer.  The TNM staging might not be appropriate.  Then I remembered the Gleason grading system for prostatic cancer.  We could randomly sample a city, challenged the samples with different staging scenarios and worked out a score.

I could not come up with a better name for the ingeniously invented staging system.  So, I called it the CM staging for carcinoma of city.    

(Source: HKMA News March 2015)

身體健康

(Source: HKMA News February 2015) 

It Is Not Easy

During the holidays I went to Chimelong Amusement Park in Guangzhou again.  Yes, again.  As I like that Park.  You can walk along in the Zoo and have close contact with quite a numbers of animals.  You can get a very close look at twenty odd pandas, a much closer look than in the Chengdu Panda Base, though you cannot pay 2000 dollars to take pictures with them.  You can also visit the 3 newborn panda triplets.  Maybe they are not quite happy with their funny new names, they are asleep most of the time.  For other animals, you can get into contact with them.  There are elephant rides, koala petting and animal feeding.  I like feeding giraffes most.  They fancy a certain type of leaves.  You can attract them by waving that kind of leaves only.  While it grabs the whole branch with its long tongue, you have ample time to take close-up pictures of its long eye-lashes.

During night time, there was nothing else to do except watching the International Circuit show.  Actually the show was great and well organized.  You must not miss it.  However, it might not appear as interesting after you had watched it a few times.  So in the intervals between pop corns and whatsapp messages, I began to notice some not-as-big-and-interesting events in the show.  There were athletes jumping from a wall and then bouncing back from a trampoline repeatedly.  That looked like cartoons and was quite funny.  My sister thought that there was no difficulty in it.  I recalled my high school days when I struggled clumsily on a trampoline and nearly broke my neck.

Many things are easier watched than done.  General practice is no exception.  I have been in general practice for more than 2 decades.  Academic-wise, I am not as bad as my trampoline skill.  I still find general practice far from easy.  Laymen, or even some colleagues, might think that general practice is seeing URTIs.  Well, yes.  General practice involves many URTIs, especially in Hong Kong.  However, among the URTIs, there are a few lung cancers, a few serious pneumonias, a few heart failures, and more asthmas than you expected, and once in a while, even a fatal syndrome we have never encountered, which was later named as SARS.  And sorry, I have to correct you that general practitioners are not seeing URTIs.  We are seeing patients with URTIs.  We see patients.  Among the patients with URTIs, there are patients with hypertension, patients with diabetes, patients with hidden colonic cancers, patients with depression, and once in a while, a patient with a rare disease that the professors in the 2 Universities have never encountered.  The scope of general practice is too large.  We are expected to know a bit of everything.  But that “a bit” is the essential bit to recognize early sinister conditions, to keep our patients healthy, and to relieve their immediate sufferings.

People like to talk about the importance of primary care and general practice.  Do they realize that general practitioners are fighting a deem-to-lose battle everyday?  Each and every of our patients will eventually develop one of the diseases that we are assumed to prevent.  There is no end point in preventive medicine.

How about the government which has been the biggest lip-service provider in primary care?  Do the officials know primary care?  Do they have a fair and accurate assessment of the importance of general practitioners?  Hong Kong is proud of the longevity of its citizens.  This fact often serves as evidence of the success of the Department of Health and the Hospital Authority.  The role of general practitioners is never mentioned.  It is estimated that general practitioners are seeing around 100,000 patients a day.  Some of them are working 7 days a week, and most of them more than 350 days a year.

On the contrary, the importance of general practice is often undermined, and general practitioners are openly attacked.  Vaccination is considered a purely mechanical procedure and can be done by non-healthcare personnel with minimal training in injection technique.  For a proper consultation, explanation of vaccination, consent signing, injection of vaccine and the taking care of any adverse reactions, a fee of $50 is paid by the government.  It has been hinted that it is a generous sum.

Another example: the Healthcare Voucher Scheme.  I am not going to repeat how absurd it was to focus on accusing general practitioners overcharging without any solid evidence.  No one was interested in investigating such matter.  No one was found overcharging and punished.  But the names of general practitioners were not cleared either.  What I wanted to remind you was the stated objective of the Scheme.  It was announced at the beginning and then reiterated in the first review that the Scheme served to encourage routine body check.  General practitioners were frowned upon for not achieving this mission impossible.  While most of the elderly were struggling with acute anomalies, they were expected to use the minimal sum of $250 for body check.  There was no added resource or facility to cater for those screened positive.

General practitioners are trained to modify behavior.  The gist of primary care rests on behavior modification.  People are encouraged to live health life styles, to vaccinate, and to look for early signs and symptoms of serious illnesses.  Behavioral modification is never easy.  The government has spent lots of money to promote vaccinations, to promote smoking cessation, to encourage regular exercise, and you name it.  It is hard to say any one of them is successful.  It is sure that sitting in the ivory tower and trying to modify the behavior of people over 70 with $250 will never succeed.

To young general practitioners and to my colleagues: don’t forget that in the course of modifying others’ behavior, our behavior is being modified too.  Our physical health might deteriorate because of the long working hours and the lack of exercise.  We might become more pessimistic and less compassionate because of repeated frustrations.  Have the government done anything to help?

(Source: HKMA News January 2015)